Columbia  (Bniftergitp 

intijeCitpirfltogark 

of  pfrpstctans  anb  burgeons 
Hibrarp 


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INAUGURAL  ESSAY, 

ON    THE 

TREATMENT  OF  WOUNDS  OF  THE 

ifpemoral  ©tin. 

SUBMITTED    TO    THE    EXAMINATION    OF 

SAMUEL  BARD,  M.D.  L.L.D. 

PRESIDENT,    AND   THE    TRUSTEES    AND   PROFESSORS   OE   THE 

COLLEGE  OF  PHYSICIANS  AND  SURGEONS  OF  THE  UNI- 
VERSITY OF  THE  STATE  OF  NEW-YORK  : 

AND  PUBLICLY  DEFENDED  FOR  THE  DEGREE  OE 

DOCTOR  OF  MEDICINE, 

ON    THE    SIXTH    DAY    OF    THE    4TH    MONTH,    1819, 


By  DANIEL  A.  ROBINSON, 

Member  of  the  Medico- Chirurgical  Society  of  the  University  of  the  State 
of  New-York. 


GENEVA,  n.  y. 

PRINTED  BY  J.  BOGEBT,   AT  HIS  BOOKSTORE  AND  BINDERY. 

1819. 


AN 


XF  we  search  (he  records  of  most  systematic  writers 
on  surgery,  it  will  be  fuund  that  very  little  is  said  of  wounds 
of  the  veins  :  however,  it  is  not  our  object  to  inquire  into  the 
cause  of  this  omission  But,  to  show  that  the  subject  is  worthy 
of  particular  examination,  we  quote  the  following  :  First,  from 
Boyer,  who  observes,  that  "  the  hemorrhage  from  a  large  vein 
may  become  very  dangerous  when  the  vein  is  the  only  one  be- 
longing to  the  limb;  for  then  the  compression  or  ligature  ne- 
cessary to  staunch  the  blood,  hinders  its  return  to  the  heart, 
and  the  member  swells  so  prodigiously  that  gangrene  may  su- 
pervene. For  example,  if  the  femoral  vein  were  opened  at  the 
groin,  above  its  juncture  with  the  saphena  vein,  there  would 
result,  from  the  compression  necessary  to  stop  the  bleeding,  a 
great  tumefaction  and  its  necessary  consequences.'''* 

Secondly.  S.  Cooper,  in  his  Surgical  Dictionary,  a  work 
30  justly  and  so  highly  esteemed,  is  silent  on  this  point.  We 
find  in  it,  however,  a  reference  to  Dr.  Hunter's  second  opera- 
tion for  popliteal  aneurism,  wherein  he  included  in  one  liga- 
ture the  femoral  vein  with  the  artery.     His  patient  died. 

Thirdly.  In  Cooper's  and  Travers's  Surgical  Essays,  a 
work  lately  published,  may  be  found  several  interesting  cases 
perfectly  in  point,  from  which  it  is  thought  proper  to  select 
the  following:  1st,  John  White,  aged  28  years,  was  admitted 
into  Guy's  Hospital  Nov.  22,  1816,  for  an  aneurismal  tumor 
in  his  left  ham.  During  the  operation  of  tying  the  femoral  ar- 
tery in  the  thigh  with  two  ligatures,  on  Friday,  Nov.  29,  1816, 
*  Vol.  1— page  124.    Alexander  H.  Stevens'  Translation. 


[     4     ] 

a  hemorrhage  took  place  from  a  small  wound  of  the  femoral 
vein.  The  bleeding  was  at  first  troublesome,  but  was  presently 
commanded  by  a  ligature  which  was  applied  around  the  opening 
by  nipping  up  its  coats.  Inflammation  ensued  in  the  vein,  and 
the  man  died  Dec.  31,  1816.  "  Examination. — The  limb,  and 
especially  the  leg  and  foot  were  oedematous ;  the  surface  of 
the  wound  was  in  a  sloughing  state,  but  it  was  filled  at  the 
bottom  by  granulations;  the  extremity  of  the  divided  artery 
presented  a  healthy  appearance ;  the  femoral  and  profunda 
veins  were  filled  by  adhesiev  matter.  When  a  blow  pipe  was 
introduced  into  the  upper  extremity  of  the  femoral  vein,  the 
air  passed  by  it  to  the  wound  externally.  The  same  was  at- 
tempted to  be  done  with  the  femoral  artery,  but  it  did  not  ap- 
pear to  have  any  communication  with  the  external  wound. 
The  vein  was  next  laid  open  :  its  internal  tunic  was  covered 
with  adhesive  matter,  and  the  sides  at  the  lower  part  were  ad- 
hering. It  contained  nothing  like  recent  blood.  All  the 
coats  were  much  thickened,  and  its  capacity  was  gradually 
diminished  downwards  to  the  wound,  where  it  was  completely 
closed.  There  was  an  opening  in  the  coats  of  the  vein  about 
three-quarters  of  an  inch  above  the  obliterated  part,  and  this 
opening  communicated  with  the  external  wound.  Below  the 
obliteration  the  wound  was  in  a  healthy  state,  the  coats  of 
the  vessel  were  natural,  and  it  contained  a  clot  of  blood.  The 
adhesive  inflammation  had  extended  from  the  internal  surface 
of  the  femoral  vein  to  the  iliac,  as  high  as  the  bifurcation  of 
the  cava.  The  cava  was  also  inflamed,  but  here  the  inflamma- 
tion had  not  produced  lymph  or  pus.  The  internal  surface  of  the 
iliac  vein  presented  the  same  appearance  as  the  femoral ;  the 
corresponding  iliac  on  the  opposite  side  was  not  affected.  The 
artery  was  next  examined:  its  internal  surface  was  healthy; 
the  lymph  plug  extended  some  considerable  distance  above  the 
situation  of  the  ligature,  and  its  extremity  was  contracted  and 
closed.  There  was  considerable  serous  effusion  in  the  chest ; 
one  of  the  lobes  of  the  left  lung  was  covered  with  a  recent 


t  5  'J 

deposit  of  lymph,  and  llie  parenchymatous  substance  of  the 
lungs  appeared  to  have  been  inflamed.  There  was  also  a 
slight  inflammatory  blush  on  the  surface  of  the  intestines;  the 
other  viscera  of  the  abdomen  appeared  in  a  healthy  state." 

Case  2nd.  "  John  Crute,  aged  30,  suffered  amputation  of 
his  right  leg  above  the  knee,  for  a  scrophulous  disease  of  that 
joint  of  long  continuance.  His  health  was  in  a  considerable 
degree  affected.  During  the  first  two  days  succeeding  the  op- 
eration, he  appeared  unusually  low,  often  sighed  deeply,  and 
spoke  but  little.  On  the  evening  of  the  third  day  it  became 
evident  that  he  labored  under  more  constitutional  irritation 
than  is  common  after  amputation,  and  he  was  attacked  at  night 
with  severe  bilious  vomiting,  his  bowels  being  freely  open. 
Early  on  the  following  morning,  (fourth  day")  the  dresser  was 
called  to  him,  and  finding  that  he  had  passed  a  very  restless 
night,  and  had  a  hard  quick  pulse,  he  drew  20  ounces  of  blood 
from  his  arm,  and  administered  some  aperient  medicine.  His 
pulse  lowered  and  became  softer,  and  he  expressed  himself  re- 
lieved by  the  bleeding;  but  the  vomiting  continued  at  inter- 
vals. At  noon  the  stump  was  opened  :  the  lips  of  the  wound, 
which  were  generally  adhering,  were  separated,  and  a  copious 
discharge  of  grumous  blood,  accompanied  with  purulent  sanies, 
followed.  A  fomentation  and  poultice  were  applied  to  the 
stump  :  in  the  evening  an  exacerbation  of  the  symptoms  took 
place ;  slight  rigors  were  followed  by  fever  and  delirium.  On  the 
morning  of  the  5th  day  his  pulse  was  thready  and  very  rapid  ; 
his  countenance  sunken,  and  he  had  incessant  low  muttering: 
he  continued  sinking  until  3  p.  m.  on  the  following  day,  when 
he  died.  Examination  twenty  hours  after  death. — The  femor- 
al artery  in  a  healthy  state  ;  a  firm  plug  of  lymph  obstructing 
the  canal,  which  was  contracted,  as  is  usual  where  a  ligature 
has  been  applied.  On  the  mouth  of  the  femoral  vein  was  a 
ligature  which  the  dresser,  in  the  absence  of  the  surgeon,  had 
applied,  for  the  purpose  of  restraining  a  hemorrhage,  after  the 
ligature  of  the  artery,  apparently  proceeding  from  the  vein  : 


[     6     ] 

he  bad  done  this  without  hesitaton,  having  frequently  seen  it 
done  with  safety  by  the  surgeon  under  whom  he  hud  formerly 
studied.  From  the  site  of  the  ligature,  along  the  femoral  and 
external  iliac  veins,  to  the  point  at  which  the  emulgents  enter 
the  latter  vessel,  the  interior  tunic  was  literally  coated  by 
large  flakes  of  coagulable  lymph.  There  were  marks  of  dif- 
fused inflammation  terminated  as  described.  The  vein  in  the 
right  arm  from  which  Crute  had  been  blooded  by  a  free  open- 
ing, was  examined.  The  integuments  had  ciosed  over  the 
wound  and  the  vessel  was  uninflamed.  Between  the  mouths 
of  the  femoral  vein  and  artery  was  discovered  a  small  branch, 
arising  immediately  above  the  ligature  of  the  artery  ;  and  this 
Vessel  was  doubtless  that  from  which  the  bleeding  had  pro-' 
ceeded." 

We  wish  to  avoid  as  much  as  possible  any  unnecessary 
multiplication  of  facts  ;  but  the  following  case  is  replete  with 
pathological  instruction,  and  for  that  reasou  we  presume  it 
will  not  be  thought  superfluous. 

Case  3d.  "  A  robust  soldier,  36  years  of  age,  was  bled  in 
the  arm  for  optha'mai,  which  was  considerably  relieved  by 
the  operation  ;  a  degree  of  fever,  however,  came  on,  and  grad- 
ually increased.  On  the  seventeenth  day  after  the  bleeding, 
his  pulse  was  one  hundred  and  twenty  in  a  minute  and  feeble; 
his  skin  w?s  hot ;  his  tongue  covered  with  a  brown  fur  ;  his  respi- 
ration difficult:  he  complained  of  great  prostration  of  strength, 
and  pain  in  his  head,  back  and  extremities.  The  wound  in 
the  vein  had  healed,  but  the  day  after  the  bleeding  great 
swelling  and  pain  commenced  in  the  arm,  and  gradually  ex- 
tended upwards.  He  was  bled  in  the  opposite  arm,  and  vari- 
ous medicines  were  administered.  The  symptoms  continued, 
with  very  little  alteration,  until  the  twenty  third  day,  when  a 
painful  swelling  was  observed  above  the  clavicle  ;  and  in  a  few 
days  afterwards,  another  soft  diffused  swelling  was  discovered 
underneath  the  angle  of  the  lower  jaw.  The  symptoms  in- 
creased slowly  ;  respiration  became  more  painful  and  difficult; 


[      7     ] 

the  pulse  was  seldom  less  than  one  hundred  and  twenty ;  he 
became  delirious,  and  died  in  the  course  of  the  seventh  week 
after  the  bleeding. 

The  following  appearances  were  observed  upon  dissec- 
tion : — the  cephalic  vein  at  the  part  where  it  had  been  punctured 
in  the  first  instance,  resembled  an  artery  in  the  thickness  of  its 
coats,  and  retained  its  circular  form  when  cut  across;  below 
the  punctured  part  it  was  healthy  ;  about  an  inch  above  the 
puncture  its  cavity  was  obliterated,  the  obliteration  extended 
to  the  shoulder;  the  branches  which  communicated  with  the 
cephalic  vein,  at  the  bend  of  the  arm,  were  healthy  ;  the  ab- 
sorbent glands  aboul  (he  clavicle  were  enlarged  and  hardened; 
the  internal  jugular  vein  was  much  enlarged,  thickened  and 
indurated  ;  the  effects  of  inflammation  were  apparent  through- 
out its  whole  course;  it  had  the  external  appearances  of  an  ar- 
tery, though  larger  than  any  artery  except  the  aorta ;  the 
subclavian,  axillary  and  brachial  veins,  to  the  bend  of  the  arm, 
exhibited  similar  appearances.  The  external  jugular  and  sub- 
clavian veins  were  filled  with  pus  :  when  slit  open  they  were 
found  to  be  much  thickened  and  lined  with  lymph.  Many  of 
the  smaller  veins  were  in  a  similar  condition.  There  was  so 
much  inflammation,  adhesion  and  induration  in  the  upper  part 
of  the  arm  that  it  was  extremely  difficult  to  trace  the  vessels, 
and  detach  them  from  their  connections  ;  the  vena  cava  superior 
was  healthy  ;  the  diseased  appearances  were  not  gradually  lost, 
but  terminated  abruptly;  the  heart  was  healthy  ;  the  lungs  con- 
tained some  small  abcesses.  A  serous  fluid,  with  flakes  of 
lymph  floating  in  it,  was  contained  in  the  cavities  of  the  tho- 
rax ;  the  lungs  adhered  to  the  pleura  costalis,  partially  on  the 
Jeft  side,  but  more  extensively  on  the  right ;  the  structure  of 
the  brain  was  natural,  but  more  serum  than  is  usual  was  found 
in  the  ventricles;  the  veins  of  the  pia  mater  were  turgid  with 
blood ;  the  vena  magna  galeni,  and  sinuses  were  remarkably 
loaded. 

Many  cases  might  be  adduced  to  show  that  ligatures,  ap- 


[     8     ] 

plied  to  large  veins,  are  not  unfrequently  productive  of  serious, 
if  not  fatal  consequences  ;  but  in  a  wound  of  a  vein  of  the 
magnitude  of  the  femoral,  something  must  be  done,  and  that 
too  with  promptitude;  otherwise  the  patient  will  soon  be  ex- 
hausted by  hemorrhage.  As  has  already  been  observed,  re- 
peated trials  have  proved  the  ligature  an  improper  application  : 
compression,  therefore,  has  been  adopted,  and  under  certain 
circumstances  it  has  been  attended  with  success.  Dr.  Rodg- 
ers,  No.  14  Corliaud-street,  informs  me  that  be  has  seen  the 
case  of  a  boy,  who,  at  play  with  a  penknife  in  his  hand,  ac- 
cidentally plunged  it  into  the  femoral  vein  high  up  in  the 
thigh,  and  although  the  hemorrhage  was  very  profuse,  yet,  by 
the  judicious  application  of  compression,  the  bleeding  was  res- 
trained and  the  boy  recovered.  Sometimes  a  ligature  applied 
to  the  femoral  vein  is  not  attended  with  any  bad  symptoms. 
Dr.  Hodgson  has  "  known  an  instance  in  which  it  was  includ- 
ed in  a  ligature  without  any  unfavorable  consequences;"*  but 
cases  of  this  kind  are,  however,  very  rare,  so  much  so  that 
the  most  scientific  surgeons  deprecate  the  application  of 
them  to  veins  upon  any  occasion,  more  especially  to  the  femor- 
al vein.  I  am  very  credibly  informed  that  Astley  Cooper,  of 
London,  has  said  that  he  would  rather  have  his  femoral  artery 
wounded  a  dozen  times,  than  to  have  his  femoral  vein  injured 
once.  When,  therefore,  a  man  so  prominent  in  science  and 
surgery  as  Astley  Cooper  is  acknowledged  to  be,  expresses  him- 
self in  the  above  terms,  it  is  time  the  sulject  had  a  most  careful 
examination.  But  before  entering  particularly  into  an  investi- 
gation of  the  treatment  of  these  injuries,  it  is  thought  best  to 
take  a  general  view  of  the  Anatomy,  Physiology  and  Pathol- 
ogy of  the  vascular  systems,  referring  more  particularly  to  the 
parts  about  the  thigh.  This  we  think  important,  inasmuch 
as  it  will  be  explanatory  of  our  views  of  the  proper  mode  of 
treatment. 

*  An  observation  made  in  fhe  dissecting-room  by  Dr.  Sullivan,  our 
Anatomical  demonstrator,  in  the  winter  of  1817 — 18. 


[     9     ] 

I.  Of  the  Arteries. 

The  arteries  are  composed  of  three  coats :  First,  an  ex- 
ternal,  membranous  or  muscular  coat,  which  13  very  elastic: 
Secondly,  a  middle,  muscular  one,  which  is  composed  of  two 
layers  of  muscular  fibres.  Those  of  the  external  layer  extend 
longitudinally,  and  are  comparatively  few.  The  fibres  of  the 
internal  layer  are  stronger  and  more  numerous,  and  are  ar- 
ranged in  segments  of  circles  around  the  artery;  but  when  col- 
lectively considered,  they  form  a  complete  circle.  The  third 
or  inner  coat  is  composed  of  a  transparent  membrane,  and 
is  remarkably  thin,  smooth,  and  dense. 

II.  Of  the  Veins. 

The  veins,  like  the  arteries,  are  composed  of  three  coats, 
and  are  arranged  in  the  same  manner;  but  are  remarkably  thin 
and  compact.  The  existence  of  a  middle  muscular  coat  has 
been  denied  by  some  anatomists,  except  in  the  larger  trunks, 
as  the  two  venae  cava?.  The  veins  are  furnished  with  valves, 
which  are  very  numerous  in  the  extremities,  and  are  general- 
ly described  as  being  formed  by  a  duplicature  of  the  internal 
membrane.  They  are  so  arranged  as  to  allow  the  blood  to 
pass  on  towards  the  heart,  but  prevent  its  reflux. 

III.  Comparative  view  of  both  sets  of  Vessels. 

The  arteries,  in  consequence  of  (he  strength  and  thick- 
ness of  their  coats,  are  opake,  and  retain  their  cylindrical 
form  when  cut  across.  The  veins,  on  the  contrary,  collapse, 
and  in  consequence  of  their  tenuity,  are  transparent.  The 
coats  of  an  artery  are  distinct,  and  can  easily  be  separated : 
those  of  a  vein  are  blended  together,  so  much  so  as  to  be  sep- 
arated with  the  greatest  difficulty.  The  veins,  in  consequence 
of  their  tenuity,  are  very  extensible,  especially  in  the  trans- 
verse direction.  The  arteries  have  not  this  property.  The 
veins,  as  has  been  shown,  are  furnished  with  valves.  The  ar- 
teries have  no  valves,  except  at  the  heart. 

Of  the  Femoral  Artery. 

The  femoral  artery,  from  the  point  where  it  emerges  from 
B 


[   io  1 

Foupart's  lament,  to  the  going  off  oF  the  profunda,  will  be 
designated  in  this  dissertation  as  the  inguinal  artery  :  also  the 
femoral  vein,  from  the  same  point  to  the  entrance  of  the  saphe° 
na  major,  will  be  known  as  the  inguinal  vein.  This  arrange- 
ment will  enalde  us  to  treat  the  subject  with  more  perspicuity. 
The  external  side  of  the  inguinal  artery  lies  immediately 
under  the  centre  of  a  line  drawn  from  the  anterior  superior 
spinous  process  of  the  os  ilium,  to  the  tuberous  angle  of 
the  os  pubis.  So,  if  it  becomes  necessary  to  cut  down  upon 
this  artery,  our  direction  is:  First,  find  the  centre  of  a  line 
drawn  between  the  two  points  of  bone  above  noticed;  then, 
laying  the  outside  of  the  finger  upon  the  point  thus  obtained, 
directly  under^'he  finder  will  be  the  artery  ;#  taking  care  to 
use  the  fore  finger  of  the  right  hand  when  examining  the  right 
thigh,  and  vice  versa.  The  inguinal  artery  is  from  an  inch 
to  an  inch  and  a  half  in  length  :  it  lies  upon  the  lower  portion 
of  the  psoas  magnus  and  iliacus  internus  muscles,  and  is  cov- 
ered only  by  tne  common  integuments,  some  of  the  inguinal 
glands  and  fascia  of  the  thigh.  There  are  several  small 
branches  of  arteries  which  proceed  from  it  to  the  parts  imme- 
diahly  in  its  vicinity,  and  to  the  external  parts  of  generation. 
The  artery,  at  its  lower  portion,  gets  deeper  in  the  thigh,  and 
opposite  to  the  trochanter  minor  divides  into  the  profunda  and 
femoral,  properly  so  called.  The  arteria  profunda  goes  to  the 
muscles  of  the  thigh,  and  its  branches  inosculate  very  freely 

*  The  outside  of  the  fore  finger  is  described  by  some  anatomisti 
to  be  that  side  which  is  next  to  the  middle  finger;  but  we  think  it  more 
natural,  if  nut  more  correct,  to  call  that  the  outside  which  is,  in  reality,  on 
the  outside  ;  and  the  inside  of  the  finger  to  be  on  that  side  which  is  near- 
est to  a  line  drawn  between  the  middle  and  ring  fingers.  This  may  be 
considered  to  be  a  matter  of  little  consequence  ;  but  when  made  use  of  in 
describing  the  local  situation  of  the  inguinal  artery,  it  becomes  a  subject 
of  serious  importance.  Our  learned  and  very  able  professor  of  anatomy, 
Dr.  Post,  in  his  lectures,  described  the  outside  of  the  fore  finger  to  be 
that  side  which  was  next  to  the  middle  finder.  It  is  hoped  the  impor- 
tance of  the  subject  may  atone  for  a  further  apology. 


[  11  ] 

with  the  branches  of  the  internal  iiiac,  antl  also  with  the  fe- 
moral and  popliteal  artery,  about  the  knee.  In  consequence 
of  its  numerous  and  free  inosculations,  it  is  considered  the  most 
important  artery  of  the  thigh. 

The  femoral  artery,  where  it  leaves  the  inguinal  artery,  lies 
pretty  deeply  in  the  thigh  ;  Itut  in  its  descent  it  soon  becomes 
more  superficial  and  runs  along  the  inner  edge  of  the  sartori- 
us  muscle  for  a  short  distance  :  it  then  takes  somewhat  of  a 
spiral  direction,  inclining  n.ore  .nwards  and  backwards,  and 
at  the  upper  part  of  the  lower  third  of  the  thigh  it  passes 
through  the  triceps  muscle,  lyiug  close  to  the  bone  on  its  pos- 
terior surface.  Continuing  in  this  direction  it  passes  be- 
tween the  condyles  of  the  os  femoris,  where  it  receives  the 
name  of  popliteal  artery. 

The  inguinal  vein  lays  on  the  inner  side  of  the  artery, 
and  close  to  it.  The  vein  is  about  the  same  length  of  the  ar- 
tery, and  from  an  inch  to  an  inch  and  a  half  below  Pouparfs 
ligament  it  receives :  First,  the  saphena  major  :  Secondly, 
from  a  quarter  to  half  an  inch  below  this  point,  the  pro- 
funda vein  enters.  The  inguinal  vein  then  receives  (he  name 
of  femoral  vein,  which  descends  in  company  with  the  femo- 
ral artery,  but  in  its  course  it  inclines  gradually  to  the  poste- 
rior part  of  the  artery,  and  after  passing  through  the  triceps 
muscle,  between  the  condyles  of  the  os  femoris  and  behind  the 
joint  of  the  knee,  it  lays  quite  posterior  to  it. 

The  saphena,  where  it  enters  the  inguinal  vein,  is  conse- 
quently pretty  deeply  seated,  but  it  soon  becomes  quite  su- 
perficial and  passes  down  on  the  inner  and  anterior  part  of  the 
thigh;  on  the  inner  side  of  the  knee  joint  and  os  tibia;  fore 
part  of  the  inner  ancle,  and  so  on  to  the  foot. 

We  think  this  description  is  sufficient  to  point  out  the  lo- 
calities of  the  artery  and  vein  under  consideration,  which  it 
has  been  our  object  more  particularly  to  da. 


[    12    j 

PHYSIOLOGY  OF  THE  ARTERIES  AND  VEINS, 

I.  Of  Arterial  Circulation. 

It  is  taken  for  granted  that  the  blood,  abstractly  consid« 
ered,  possesses  no  power  of  its  own  by  which  it  is  enabled  to 
propel  itself  forward  :  that,  in  this  respect,  it  is  like  any  other 
fluid,  and  subjected  to  the  same  laws  of  gravity  and  pressure. 
By  this,  however,  we  do  not  pretend  to  deny  that  it  posses- 
ses vitality;  on  the  contrary,  it  is  admitted.  The  various 
changes  which  are  effected  in  the  pabulum  of  animal  exist- 
ence from  the  time  the  food  is  comminuted  in  the  mouth,  un- 
til it  becomes  a  constituent  part  of  the  general  system,  pas- 
ses through  successive  degrees  of  animalization  and  conse- 
quently corresponding  degrees  of  vitality.  Therefore,  if  we 
were  called  upon  to  define  the  blood,  we  should  call  it  that 
substance  in  a  fluid  state  which,  after  having  passed  through 
several  successive  degrees  of  animalization  and  vitality,  be- 
comes fitted  for  the  heart  and  arteries,  and  by  its  presence  and 
its  peculiar  properties,  stimulates  them  to  action,  and  which 
the  arteries  convey  to  the  different  parts  of  the  system  for  its 
nourishment  and  support. 

The  degree  of  agency  which  the  arteries  exert  in  propel- 
ling forward  their  contents,  is  what  we  are  particularly  desir- 
ous to  examine  and  elucidate ;  for  a  knowledge  of  this  will 
direct  us  to  one  of  the  most  important  indications  in  the  treat- 
ment of  wounds  of  the  femoral  vein. 

The  blood,  after  being  thrown  into  the  aorta,  is  prevent- 
ed from  returning  to  the  heart  by  the  semilunar  valves,  con- 
sequently, when  compressed  by  the  contraction  of  the  arteries, 
it  must  necessarily  flow  in  that  direction  in  which  it  finds  the 
least  resistance  :  this  of  course  will  be  towards  their  extremi- 
ties. That  the  blood  is  urged  forward  by  the  contraction  of 
the  arteries  alone,  we  are  far  from  believing  :  the  impetus  giv- 
en to  it  by  the  action  of  the  heart,  is  very  great.  However, 
that  the  arteries  themselves  do  possess  very  considerable  a- 
gency  in  propelling  forward  their  contents,  is  inculcated  by 


[    13   ] 

some  of  our  most  enlightened  physiologists.  The  strength 
of  their  coats,  their  muscularity,  and  the  fact  which  before  was 
not  adverted  to,  of  their  muscular  fibres  (comparatively  con- 
sidered) increasing  in  the  extreme  branches,  favor  the  idea 
that  the  more  distant  the  arteries  are  situated  from  the  heart, 
the  more  the  blood  is  dependant  on  them  for  its  motion. 

It  may  be  observed  that  the  gravity  of  the  blood  has  a 
very  considerable  effect  in  facilitating,  and  consequently  ac- 
celerating its  circulation  through  the  arteries  of  the  lower  ex- 
tremities when  the  body  is  in  an. erect  posture.  However,  of 
gravity  and  pressure  we  shall  have  somewhat  to  say  when 
speaking  of  the  treatment. 

II.  Of  Venous  CtRcuLATioN. 

The  veins,  originating  from  the  numerous  and  very  ex- 
treme arteries,  receive  their  blood  and  convey  it  back  again 
to  the  heart.  In  this  act  the  veins,  of  themselves,  are  passive, 
or  if  they  exert  any  power,  it  is  very  inconsiderable  in  effect. 
The  fluid  which  they  contain  is  also  passive,  that  is,  abstract- 
ly considered,  it  is  so.  Neither  is  any  action  excited  in  them 
by  the  heart's  contraction.  The  blood,  however,  is  returned 
by  them  to  the  heart,  and  some  power  must  operate  to  e  fleet 
this.  The  veins,  as  has  been  shown,  are  furnished  with 
valves.  These  are  very  numerous,  and  exist  in  the  greatest 
number  in  the  extremities.  They  allow  the  blood  to  pass  to- 
wards the  heart,  but  prevent  its  reflux.  Therefore,  bearing 
in  mind  their  anatomical  structure,  we  attempt  a  solution  of 
their  function,  thus  :  as  the  veins  originate  from  the  termina- 
tion of  the  extreme  arteries,  there  is  the  strongest  probability 
that  the  blood  may  be  conveyed  in  them  for  some  distance 
by  the  impetus  which  it  has  received  from  the  arteries;  and 
as  two  veins  generally  accompany  one  artery,  and  at  the 
same  time  lay  in  close  contact  with  it,  one  on  either  side  ; 
that  in  this  situation  the  pulsation  of  the  artery  affecting  the 
veins,  will  compress  them,  and  then  allow  them  to  dilate. 
Therefore,  in  the  diastole  of  the  artery,  the  veins  will  be  com- 


C    ™    ] 

pressed,  and  by  heing  thus  acted  upon,  the  Wood  which  they 
contain  is  set  in  motion,  and  as  the  valves  prevent  its  reflux, 
it,  of  course,  must  flow  on  towards  the  heart ;  because,  in  that 
direction  it  meets  with  the  least  resistance.  Then,  in  the 
systole  of  the  artery  the  veins  being  uncompressed  and  com- 
paratively empty,  are  allowed  to  fill  again.  Thus,  by  the  al- 
ternate action  and  reaction  of  the  arteries  compressing  and 
unloading  the  veins,  the  blood  is  urged  forward  in  them  to- 
wards the  heart. 

It  may  be  conceived,  and  the  idea  advanced,  that  this 
theory  is  insufficient  to  elucidate  venous  circulation.  But  it 
should  be  recollected  that  the  Oiaslole  of  all  the  arteries, 
which  are  very  numerous,  occurs  at  one  instant  of  time,  and 
therefore  the  united  area  of  distention  which  they  make  will 
be  very  considerable  :  this  applied  to  the  veins,  will  make 
compression  on  them  in  the  same  ratio  ;  and  on  the  other  hand, 
the  systole  of  all  the  arteries  takes  place  at  a  corresponding 
period,  thereby  allowing  the  veins  to  fill  again.  In  addition 
to  the  above,  it  may  be  mentioned,  that  the  strong  aponeuro- 
sis which  covers  all  the  muscles  and  main  mass  of  blood  ves- 
sels of  the  thigh  and  leg,  is  dense,  non  elastic  and  unyielding; 
so,  the  diastole  of  the  arteiies  meeting  with  this  resistance 
from  without,  must  consequently  effect  compression  more  im- 
mediately upon  the  softer  parts  within — the  veins. 

In  this  view  of  the  manner  in  which  venous  circulation 
is  effected,  the  limn  or  extremity  has  been  supposed  to  lie  in 
an  easy,  natural  position,  peifi  ctly  quiet  and  at  rest.  But,  if 
the  muscles  are  put  in  action,  the  compression  which  they 
will  make  upon  the  vein*  will  be  so  considerable,  that  the 
blood  will  be  propelled  towards  the  heart  with  greater  force; 
and,  as  muscular  contraction  is  not  incessant,  but  attended 
with  periods  of  relaxation,  time  is  thereby  allowed  for  the 
veins  to  fill  again:  so,  by  muscular  action  venous  circulation 
is  accelerated. 

The  blood  is  moved  in  the  veins  in  a  slow  and  progres- 


[    15    ] 

sive  manner;  and  in  the  lower  extremities  in  particular,  it  is 
urged  forward  against  the  power  of  its  own  gravity. 
OF  PATHOLOGY. 

For  observations  on  the  pathology  of  the  blood  vessels,, 
we  are  more  indebted  to  Dr.  Travers  than  any  other  writer; 
and,  indeed,  he  is  the  only  person  who  has  paid  any  particu- 
lar attention  to  it.  Therelore,  on  the  present  occasion,  we 
shall  make  liberal  use  of  the  materials  with  which  his  talents 
have  furnished  us. 

Under  the  head  of  pathology  will  be  included  the  natu- 
ral process  obseived  in  the  healing  of  wounds  of  veins;  the 
effect  which  a  ligature  has  upon  arteries  and  vein9,  and  their 
morbid  peculiarities  under  high  excitement;  and  also,  the  re- 
sources instituted  by  nature  when  the  principal  trunk  of  an  ar- 
tery or  vein  is  obliterated. 

I.  Of  the  Healing  of  Wounds  of  Veins. 

"  When  a  vein  is  wounded  longitudinally  or  obliquely, 
there  is  no  separation  of  the  edges  of  the  incision,  so  that  on- 
ly a  little,  if  any  blood,  trickles  from  the  aperture,  unless  pres- 
sure be  made  nearer  to  the  heart,  to  obstruct  the  passage  of 
the  blood  in  the  vessel.  If,  therefore,  an  animal  be  killed  im- 
mediately after  a  wound  of  the  vein  from  which  no  blood 
has  been  drawn,  the  lips  of  the  wound  will  be  found  in  con- 
tact ;  and  if  permitted  to  live  for  a  short  time,  the  cicatrix 
will  form  a  line. 

"  If  a  vein  is  opene'd  by  a  transverse  section,  it  bleeds 
without  the  addition  of  pressure ;  and  if  the  vein  is  half  divi- 
ded, the  hemorrhage  is,  with  much  difficulty,  suppressed — -the 
blood  escaping  into  the  cellular  sheath  of  the  vein,  and  of  the 
contiguous  mu.-cles  in  the  direction  of  the  current,  and  form- 
ing a  distinct  coagulum  between  the  orifice  and  the  external 
wound.  The  longitudinal  or  oblique  wound,  by  which  blood 
Las  issued  in  quantity,  presents  the  same  appearances  :  an 
oval,  naked  coagulum  forms  the  plug  of  the  orifice,  and  a  flat- 
tened covered  clot,  which  is  an  extravasation  into  the  cellular 


[    16    ] 

sheath,  extends  to  some  distance  around  it.  At  the  end  of 
twenty-four  hours  the  lips  of  the  wound  are  found  separated, 
forming  an  oval  proportioned  to  the  length  of  the  incision; 
the  edges  everted  and  adhering  to  those  of  the  clot ;  the  ever- 
sioo  seeming  to  be  the  effect  of  distention  from  the  extravasa- 
tion into  the  sheath :  there  is  no  blush  upon  the  edges,  nor  a- 
ny  appearance  of  organiz-tble  or  secreted  lymph  in  the  vein  or 
the  wound.  At  three  days  the  same  appearances  are  observ- 
ed, but  the  internal  margin  of  the  wound  is  somewhat  eleva- 
ted and  rounded,  and  a  thin  and  narrow  membranous  expan- 
sion is  perceived  to  be  continuous  with  the  everted  edge  of  the 
internal  tunic;  the  clot  itself  is  more  compact,  and  upon 
section  presents  concentric  lamella?,  the  interior  being  of  a 
lighter  color  than  the  exterior  layers. 

"On  the  fifth  day  these  appearances  are  more  confirmed; 
the  membranous  appearance  extends  over  the  surface  of  the 
clot,  if  the  wound  is  not  exceeding  a  quarter  of  an  inch  in 
length;  and  in  larger  wounds  the  coagulum,  which  is  reduc- 
ed in  size,  has  a  membranous  surface.  On  the  eighth  day  the 
new  membrane  is  complete  ;  the  interior  margin  of  the  Avound 
is  raised  and  tumid,  and  the  coagulum  of  a  common  bleeding 
wound  is  nearly  absorbed.  From  the  twelfth  to  the  sixteenth 
day,  numerous  vasa  vasorum  may  be  seen  by  the  aid  of  a 
glass,  passing  from  the  internal  tunic  over  the  new-formed 
membrane,  and  anastomosing  upon  it.  At  the  latter  period 
the  edges  are  less  raised,  so  as  to  be  more  upon  a  level  with 
the  new  membrane,  and  have  a  slight  red  blush.  The  coagu- 
lum is  entirely  absorbed.  On  the  twentieth  day  it  is  only 
possible  to  distinguish  the  recent  from  former  wounds  by  the 
tenuity,  smoothness  and  transparency  of  the  new  membrane 
compared  with  the  o'd,   which  is  dense,  tough  and  wrinkled. 

"  This  description  applies  to  wounds  of  the  size  usually 
made  in  bleeding  :  the  process  is,  of  course,  longer  in  comple- 
tion, though  not  otherwise  d'fferent  in  those  which  are  more 
extensive.     The  coagulum  which  forms  the  plug,  is  exactly 


E    17    ] 

proportioned  to  the  size  of  the  wound.  The  site  and  extent 
of  the  wound  are  ever  afterwards  marked  by  the  membrane 
which  occupies  it,  which  is  thinner,  more  transparent,  and 
more  extensile  than  the  proper  parietes  of  the  rein.  It  forms, 
when  the  vein  is  filled,  a  pouch  or  bag;  and  the  jugular  veins 
of  horses  present  many  of  these  contiguous  to  each  other. 
Farriers  avoid  bleeding  in  these  pouches,  because  they  find  it 
difficult  to  staunch  the  blood.  I  at  first  supposed  that  this 
was  a  condensed  cellular  membrane,  formed  by  the  sheath  of  the 
vein;  but  I  am  satisfied  that  it  is  continuous  with  the  everted 
edges  of  the  internal  tunic,  and  organized  by  its  vessels.  If  it 
were  consistent  with  what  we  know  of  reproduction,  I  should 
be  disposed  to  couclude,  that  the  new  membrane  was  formed 
out  of  the  coagulum  of  the  blood,  although  I  found  that  the 
coagulum  could,  with  care,  be  detached  from  the  membrane, 
which  was  continuous  with  the  everted  edge  of  the  internal 
tunic.  The  new  membrane  is,  however,  evidently  denser 
than  the  valves,  iu  structure,  which  are  said  to  be  prolonga- 
tions or  even  duplicatures  of  the  proper  tunic."* 

II.  The  Effect  which  a  Ligature  has  upon  Arte- 
ries and  Veins  ;  and  their  Morbid  Peculiarities 
under  high  Excitement. 

1st.  When  a  ligature  is  drawn  tightly  around  an  artery, 
it  causes  a  separation  of  its  internal  and  middle  coats.  In- 
flammation at  the  place  of  stricture,  and  tor  a  short  distance  a- 
round  it,  ensues;  coagulating  lymph  is  then  thrown  out  and 
an  union  of  the  sides  pf  the  artery  is  soon  effected.  The  part 
immediately  around  which  the  ligature  is  passed  ulcerates, 
and  iu  a  short  time  a  division  of  the  artery  takes  place,  and 
the  ligature  is  then  discharged.  No  extension  or  diffusion  of 
the  inflammation  takes  place;  no  constitutional  affection  is 
thereby  induced ;  the  injury  is  merely  a  local  one,  and  produc- 
tive of  no  evil  effect. 

*  Cooper's  and  T  ravers'  Surgical  Essays,  part  first. 
G 


i  is  ] 

It  then  may  be  said  of  arteries,  they  inflame  readily,  heal 
quicHy,  and  no  constitutional  affection  is  thereby  induced. 

2d.  When  a  ligature  is  put  around  a  vein  and  drawn 
tightly,  it  does  not  cause  a  division  of  its  internal  and  middle 
coats,  but  the  vein  fails  in  longitudinal  folds.  That  part  next 
the  heart  collapses,  the  other  end  is  distended  with  blood, 
which  soon  coagulates.  There  is  no  redness  or  other  signs  of 
inflammation  on  the  internal  tunic ;  consequently,  no  adhesion 
takes  place,  and  no  agglutination  of  the  contiguous  folds,  but 
the  cellular  sheath  is  thickened  by  a  deposit  of  lymph  in  the 
vicinity  of  the  ligature,  which,  after  a  little  time  becomes  so 
considerable  as  to  encompass  the  ligature  :  ulceration  ensues, 
and  about  the  fifteenth  or  twentieth  day  the  ligature  is  cast  off: 
no  thickening  of  the  proper  coats  ensues,  nor  appearances  of 
inflammatory  action  within  the  canal,  neither  of  the  upper  nor 
lower  portion  of  the  vein.  But  when  inflammation  of  the 
vein  does  ensue,  it  extends  along  the  vein  towards  the  heart, 
sometimes  from  the  point  of  irritation  as  far  as  the  right  auri- 
cle. Lymph  is  effused,  which  coats  the  inner  tunic  of  "  the 
vein  like  a  fringe;  and  though  the  quantity  effused  is  some- 
times sufficient  to  obstruct  the  tube,  the  inflammation  is  not 
bounded  by  the  obstruction."  Pus  is  sometimes  effused,  "  and 
the  inflammation  is  often  mixed,  presenting  both  terminations 
alternately,  viz.  in  lymph  and  pus.',# 

Although  the  inflammation  generally  extends  from  the 
point  of  irritation  towards  the  heart,  or  from  branch  to  trunk, 
yet,  "  in  some  instances  the  inflammation  has  extended  down- 
wards as  weil  as  upwards  in  the  course  of  the  vein.  The  same 
symptoms  have  taken  place  when  the  inflammation  has  been 
excited  by  the  application  of  a  ligature."! 

In  a  summary  view  of  the  pathology  of  the  veins,  it  may 
be  said  they  are  not  very  susceptible  of  inflammation,  and 

*  Cooper's  and  Travera'  Surgical  Essays,  page  242,  vol.  1. 

t  Hodgson,  on  Diseases  of  Arteries  and  Veins,  page  515. 


[    19    J 

when  it  does  ensue,  it  spreads  very  extensively,  producing 
great  constitulioual  irritation  wilb  all  ils  dreadful  consequences. 

It  therefore  becomes  very  important  to  know  when  in- 
flammation of  the  vein  does  ensue  while  compressed  by  a  liga- 
ture. We  may  reply,  "  the  fatal  catalogue  of  tied  veins" 
has  induced  surgeons  to  proscribe  its  application  to  them.  We 
are  aware  that  there  are  many  cases  on  record  wherein  no 
unfavorable  symptoms  have  followed  the  application  of  a  liga- 
ture;  but  it  may  be  observed,  that  these  successful  cases  are 
more  particularly  confined  to  the  ligation  of  veins  about  the 
neck,  thereby  assisting  to  confirm  the  fact,  that  wounds  of 
the  upper  part  of  the  body  heal  quicker,  and  with  less  injury 
to  the  constitution,  than  those  of  the  same  extent  and  nature 
of  the  inferior  extremities. 

III.  Op  Collateral.  Circulation. 

1st.  Of  arterial  collateral  circulation. — It  is  a  fact  well 
established  in  surgery,  that  the  circulation  will  he  carried  on 
in  a  limb  sufficient  for  its  support,  even  though  its  principal 
artery  be  obliterated.  This  fact  has  been  repeatedly  proven 
by  the  many  successful  operations  on  the  external  iliac  artery, 
(and  there  might  be  added  the  subclavian  artery,  and  even  the 
arteria  innominata*)  and  accordingly,  at  the  present  day  this 
artery  is  ligated,  without  hesitation,  as  often  as  circumstances 
render  it  necessary. 

2d.  Of  venous  collateral  circulation.— rThe  principal  vein 
of  a  limb  is  not  obliterated  with  the  same  freedom  or  confi- 
dence of  success.  However,  there  are  on  record  some  very 
singular  cases  of  obliterated  veins,  which  are  worthy  of  being 
noticed.  Dr.  Balie  mentions  an  instance  in  which  the  vena 
cava  inferior,  of  a  female  subject,  was  obliterated  from  the  en- 
trance of  the  emulgents  to  the  right  auricle  of  the  heart.  "  In 
this  remarkable  case,  the  vena  cava  inferior  was  obliterated 
where  the  venae  cavas  bepaticee  open  into  it,  so  that  not  only 

*  The  Medical  and  Surgical  Register  of  Cases  in  the  New-York  Hos- 
pital, 18iS. 


[  20  ] 

the  blood  from  {he  lower  extremities,  but  also  that  from  the 
liver  must  have  passed  through  collateral  channels  to  the 
heart.* 

Dr.  Hodgson  et  has  seen  two  instances  in  which  the  com- 
mon iliac  vein  was  obliterated,"  In  one  of  them,  "  the  exter- 
nal and  internal  iliac  veins  on  the  left  side  were  obliterated 
by  the  pressure  of  an  aneurism  of  the  abdominal  aorta;  the 
vena  azygos  was  as  large  as  the  little  finger,  and  extended  on 
the  left  side  info  the  loins,  where  it  received  two  considerable 
branches  which  communicated  with  the  lumbar  veins,  and 
with  branches  which  came  from  the  pelvis."  "  In  both  these 
cases  there  were  no  symptoms  which  indicated  obstruction  in 
the  venous  circulation  during  the  life  of  the  patients." 

The  two  preceding  cases  have  been  selected  more  par- 
ticularly on  account  of  the  fact  which  was  contained  in  the 
last  clause,  viz.  that  "there  were  no  symptoms  which  indi- 
cated obstruction  in  the  venous  circulation  during  the  life  of 
the  patients."  This  is  what  could  not,  a  priori,  be  looked  for: 
however,  it  leads  us  more  strongly  to  conclude,  that  the  oblit- 
eration must  have  taken  place  in  a  very  gradual  manner,  thus 
allowing  the  collateral  veins  to  enlarge  by  slow  degrees;  for 
if  even  the  external  iliac  vein  was  obliterated  suddenly,  and  at 
the  same  time  the  principal  artery  of  the  thigh  perform  its 
function,  there  is  the  strongest  probability  that  the  tumefac- 
tion of  the  limb  would  be  so  great  that  gangrene,  and  ulti- 
mately death,  would  ensue. 

Having  thus  completed  our  original  design,  of  giving  a 
view  of  the  importance  of  the  subject  under  consideration ; 
and  also^the  anatomy,  physiology  and  pathology  of  the  blood- 
vessels, more  particularly  of  the  thigh,  we  are  now  prepared 
to  enter  into  a  particular  investigation  of  the  treatment,  com- 
mencing— 

Firstly.  With  wouuds  of   the  Inguinal  vein. 

Secondly.  With  those  of  the  proper  Femoral  vein. 

*  Hodgson,  on  the  Diseases  of  Arteries  and  Veins,  page  526. 


[    21    ] 

Wounds  of  either  vein  will  be  divided  according  to  the 
nature  of  the  injury:  1st.  Incised  wounds,  or  those  caused 
by  cutting  instruments.  2d.  Lncerated  or  contused,  as  those 
caused  by  musket  balls,  blunted  instruments,  &c.  3d.  Ulce- 
rated or  sloughing  wounds,  as  those  produced  by  a  corroding 
ulcer,  or  sloughing  bubo  or  ulcer,  &c. 

Incised  wounds  will  be  subdivided  into,  First,  Longitu- 
dinal.    Secondly,  Transverse. 

Of  Longitudinal  Incised  Wounds  of  the  Inguinal 
Vein. 

A  surgeon,  when  called  to  a  person  bleeding  profusely 
from  a  wound  of  the  inguinal  vein,  (and  the  same  applies  to 
blood-vessels  in  general,)  will  have  his  attention  directed  im- 
mediately to  the  hemorrhage,  and  accordingly  his  indications, 
which  are  naturally  suggested,  are,  1st,  to  restrain  the  bleed- 
ing. 2d,  To  devise  the  best  means  for  speedily  healing  the 
wound. 

Means  of  accomplishing  the  first  indication: — Compres- 
sion in  wounds  of  veins  is  generally  resorted  to,  and  in  most 
cases  it  is  the  best  means  that  can  be  adopted :  accordingly, 
in  longitudinal  incised  wounds  of  the  inguinal  vein,  it  would 
be  entirely  entrusted  to;  but  an  elevated  position  of  the  foot 
we  think  an  important  auxiliary,  not  only  in  this  particular 
case,  but  in  wounds  of  the  blood-vessels  of  the  thigh  and  leg 
generally.  Therefore,  our  uotions  respecting  this  particular 
position  will  be  given  in  full,  before  proceeding  any  further 
with  a  detail  of  treatment. 

An  elevated  position  of  the  foot  is,  we  believe,  not  men- 
tioned by  any  systematic  writer  on  surgery,  as  being  worthy 
of  notice  in  the  treatment  of  wounds  of  the  blood-vessels. 
Therefore  it  is  deemed  expedient  to  be  more  particular  in  an 
investigation  of  the  subject. 

In  our  physiological  remarks  it  was  observed,  that  the 
blood,  abstractly  considered,  possessed  no  power  of  its  own 
by  which  it  was  enabled  to  propel  itself  forward ;  that,  in  this 


[    22    ] 

respect,  it  was  like  any  other  fluid,  and  subject  to  the  same 
laws  of  gravity  and  pressure. 

Of  fluids  it  is  commonly  said,  '  they  press  equally  on  all 
sides  at  the  same  height.'  But  to  make  the  subject,  as  we  think, 
a  little  more  explicit,  we  say  that  fluids,  in  consequence  of 
their  gravity,  have  a  tendency  to  disperse  and  flow  in  that 
direction  in  which  they  find  the  least  resistance,  and  the  force 
of  their  dispersing  power,  or  gravity,  is  in  proportion  to  the 
height  of  their  column.  Therefore,  when  the  hody  is  in  an 
erect  posture,  the  arterial  blood  of  the  lower  extremities  flows 
with  freedom  and  ease,  because  it  is  then  assisted  by  its  own 
gravity,  which  has  the  pressure  of  the  column  of  blood  from 
the  top  of  the  head  to  assist  in  urging  through  the  branches 
of  the  lower  extremities.  It  is  presumed  the  truth  of  this  as- 
sertion will  not.  be  questioned  by  any  who  know  that  fluids 
press  equally  on  all  sides  at  the  ssme  height,  whether  contain- 
ed in  a  straight  tube  or  one  having  as  many  branches  and  con- 
volutions as  (he  numerous  arteries  of  our  frame. 

Now,  if  the  posture  of  the  body  he  changed,  and  the  foot 
be  elevated,  (which,  when  a  person  is  lying  on  his  back,  may 
be  raised  to  an  angle  of  45°  and  even  55°  without  occasioning 
any  pain  from  tension  of  the  muscles  on  the  posterior  part  of 
the  thigh,)  then  the  gravity  of  the  blood  will  operate  so  as  to 
retard  arterial  circulation  in  the  limb;  and  if  our  patient  be  a 
person  of  ordinary  height,  or  five  feet  and  ten  inches,  bis 
whole  leg  and  foot  will  be  two  feet  and  eleven  inches  long  ; 
taking  for  granted  the  thigh,  leg  and  foot  to  be  half  the  length 
of  the  whole  frame,  which,  as  a  general  principle,  is  correct. 
—Then  his  foot  raised  to  an  angle  of  45°  will  be  two  feet  from 
an  horizontal  plane,  or  if  at  55°  it  will  be  two  feet  and  a  half; 
therefore,  the  effect  which  an  elevMted  position  has,  will  be  e- 
qual  to  the  gravity  of  a  column  of  blood  two  feet,  or  two  feet 
and  a  half  high,  which,  doubtless,  from  what  has  already  been 
said,  will  now  be  perceived  to  have  very  considerable  effect 
to  retard  the  circulation.     But  the  flow  of  arterial  blood  into 


[    23    ] 

the  limb  when  the  foot  is  elevated,  may  be  shown  to  be  les- 
sened on  a  different  |>rincij>le  than  that  of  gravity  alone.  Thus 
the  blood,  by  its  pressure  and  its  peculiar  properties,  stimulates 
the  heart  and  arteries  to  action,  and  the  strength  and  force  of 
their  contraction  is  dependant  very  much  upon  the  quantity  of 
blood  present  in  them.  If,  for  instance,  the  quantity  be  very 
small,  there  is,  of  course,  less  stimulus  applied,  consequently, 
there  will  be  less  action  produced:  the  alteration  of  the  pulse, 
so  universally  effected  from  the  common  operation  of  blood-let- 
ting, is  sufficient  to  illustrate  this  fact.  Therefore,  when  the 
foot  is  elevated,  and  part  of  the  blood  abstracted  from  the 
limb  by  its  gravity,  this,  operating  as  blood-letting,  lessens  the 
contractile  power  of  the  arteries,  which  disenables  them  to 
urge  forward  their  remaining  contents  with  the  same  degree  of 
energy  as  formerly.  Moreover,  it  must  appear  evident  to  all, 
that  the  great  distance  at  which  (he  extreme  arteries  of  the 
foot  and  leg  are  situated  from  (he  heart,  allows  an  elevated  po- 
sition of  the  loot  to  command  a  vast  influence  over  arterial 
circulation,  to  retard  it. 

When,  therefore,  it  is  established  that  an  elevated  posi- 
tion of  the  loot  does  retard  the  flow  of  arterial  blood  into  the 
limb,  it  is  clear  there  cannot  be  so  much  to  be  returned  by  the 
veins;  consequently,  the  hemorrhage  cannot  be  so  dangerous. 
But  (his  is  not  the  only  advantage  which  position  affords;  for 
when  the  foot  is  elevated  it  favors,  in  the  highest  possible  de- 
gree, the  ready  circulation  of  venous  blood.  The  valves,  in 
this  position,  are  of  no  use;  because  the  blood,  as  soon  as  it 
gets  into  the  veins,  flows  towards  the  heart  by  the  power  of 
its  own  gravity.  But  if  the  limb  be  in  a  horizontal  posture, 
er  more  particularly  if  the  foot  be  a  little  depressed,  the  blood 
is  urged  on  towards  the  heart  by  a  vis  atergo;  consequently, 
all  the  veins  of  the  limb  will  be  full,  and  even  distended  with 
blood.  It  is,  therefore,  evident,  that  under  these  circumstan- 
ces hemorrhage  will  be  more  profuse,  and  far  more  difficult  to 
restrain  than  when  the  foot  is  elevated.     Besides,  when  the 


[    24    ] 

column  of  venous  blood  is  considerably  lessened,  and  what  re- 
mains is  placed  under  the  most  favorable  circumstances  for 
its  circulation,  it  is  evident  there  cannot  be  any  accumula- 
tion of  blood  in  the  veins  to  make  lateral  pressure ;  but  on  the 
contrary,  the  veins  being  half  empty,  and  verging  towards  a 
collapsed  state,  not  only  will  favor  very  much  the  coaptation 
of  the  sides  of  a  longitudinal  wound,  but  will,  to  a  very  great 
degree,  lessen  the  hemorrhage.  Therefore,  in  longitudinal  in- 
cised wounds  of  the  inguiual  vein  our  practice  would  be, 
First,  an  elevated  position  of  the  foot.  Secondly,  lateral  com- 
presses to  be  placed  on  either  side  of  the  wound.  Thirdly, 
a  circular  bandage  applied  so  as  to  secure  the  compresses. 
This,  we  presume,  is  all  that  will  be  necessary.  Care,  how- 
ever, should  be  taken  not  to  draw  the  circular  bandage  too 
tight;  for  it  cannot  be  necessary,  and  if  pressure  be  made  so 
as  to  retard  the  flow  of  blood  through  the  vein,  it  certainly 
would  do  injury. 

Of   Transverse   Incised  Wounds   of   the  Inguinal 
Vein. 

The  degree  of  danger  attending  wounds  of  this  descrip- 
tion will  depend  upon  the  extent  and  depth  of  the  incision ; 
but  all  transverse  wounds,  more  especially  of  the  inguinal  vein, 
are  infinitely  more  dangerous  than  longitudinal  ones :  the  rea- 
son of  this  is  very  obvious:  the  longitudinal  contraction  of 
the  vein  separates  the  edges  of  the  wound,  and  thereby  pro- 
duces a  circular  hale  in  the  vein,  which  will  admit  a  more 
ready  exit  for  the  blood  :  this  hole  will  be  larger  or  smaller  in 
proportion  as  the  wound  of  the  vein  is  more  or  less  extensive. 

If  the  incision  be  a  small  one,  and  the  hemorrhage  not 
very  considerable,  the  treatment  recommended  in  the  prece- 
ding case  wUl  be  applicable  in  this,  viz.  an  elevated  position 
of  the  foot,  and  compression. 

Id  all  transverse  wounds  there  will  be  more  or  less  re- 
traction of  the  common  integuments,  as  well  as  the  coats  of 
the  vein.     Consequently,  this  will  afford  a  freer  exit  for  the 


[    25    ] 

blood.  This  circumstance  might  Induce  the  surgeon  to  make 
use  of  a  stitch  to  bring  the  sides  of  the  wound  in  contact :  if 
the  needle  be  directed  no  deeper  than  merely  through  the 
skin,  or  ou!jr  a  little  disfance  below  it.  it  may  then  be  admis- 
sible, and  even  proper ;  but  beware  of  "  nipping  up  the  coats" 
of  the  vein  for  the  purpose  of  applying  a  ligature  around 
them  : — this  practice,  experience  has  shown,  is  fraught  with 
danger,  and  should  be  deprecated.  There  is  the  greatest 
probability  that  the  closure  of  the  wound  externally  by  a 
stitch,  with  moderate  and  judicious  compression,  the  hemorr- 
hage will  be  restrained ;  observing,  at  the  same  time,  an  ele- 
vated position  of  the  foot  as  important,  in  a  high  degree.  But 
when  the  vein  is  nearly  or  quite  divided,  the  danger  from  he- 
morrhage becomes  exceedingly  great :  in  short,  it  is  one  of 
the  most  alarming  and  difficult  cases  surgeons  have  to  contend 
with.  If  we  are  fortunately  called  in  at  the  moment,  and 
compression  be  promptly  applied,  the  bleeding  may  be  res- 
trained; but  if  it  be  continued  long  "the  member  swells  so 
prodigiously  that  gangrene  may  supervene."  Therefore,  on 
an  occasion  like  the  present,  we  stand  in  need  of  all  the  infor- 
mation which  the  science  of  surgery  can  afford. 

When  recounting  the  condition  of  our  patient  and  laying 
our  plans  for  his  cure,  it  is  not  sufficient,  it  is  not  right  to 
look  no  further  than  the  bleeding  orifice,  and  there  confine  all 
our  endeavors  for  his  relief.  It  is  well  known  that  the  veins 
receive  their  blood  from  the  extreme  branches  of  arteries,  and 
consequently,  when  a  vein  is  divided,  it  bleeds  from  the  lower 
portion  of  the  orifice ;  however,  it  may  be  supposed  to  pro- 
ceed also  from  the  superior  portion  of  the  vein ;  but  for  the 
most  part  it  will  be  found  that  the  perfection  of  the  valves  is 
a  security  against  any  danger  from  this  source.  Though  we 
have  not  been  able  to  examine  a  variety  of  subjects,  yet,  hav- 
ing an  opportunity  a  few  days  ago  in  our  dissecting  room  of 
closely  inspecting  one,  it  was  found  in  this  subject  that  the 
valves  were  perfect  immediately  under  Poupart's  ligament :  so, 

D 


[    20    ] 

even  (hough  the  inguinal  vein  should  be  completely  divided, 
there  would  be  no  reflux  of  blood  from  the  external  iliac. 
Whether  a  valve  is  invariably  found  at  the  above  place,  we 
are  unable  to  say;  but,  as  the  epigastric  vein  and  circumflex 
vein  of  the  os  ilium  enter  the  externa!  iliac  almost  directly  un- 
der Pouparfs  ligament;  are  pretty  large  in  size,  and  from  the 
fact  that  valves  are  most  generally  found  where  large  veins 
are  entering,  it  may  be  fairly  conjectured  that,  as  a  general 
rule,  there  is  a  valve  situated  under  Poupart's  ligament.  If 
this  be  the  case,  the  retrograde  course  of  the  blood  will  be 
stopped,  and  hemorrhage  proceed  from  the  lower  portion  of 
the  divided  vein  only. 

Now,  if  there  be  a  valve  in  the  upper  portion  of  the 
vein,  the  blood  above  it,  taking  a  retrograde  course,  is  stopped 
by  the  valve,  which  will  thereby  not  only  keep  the  vein  dis- 
tended, but,  by  its  pressure  upon  the  valve,  will  render  it  in 
some  degree  tense;  and  the  venous  blood  from  below,  meeting 
with  this  resistance,  and  at  the  same  time  finding  an  open  pas- 
sage externally,  will,  of  course,  all  pass  in  that  direction. 
Now,  to  restrain  the  bleeding,  it  will  be  necessary  to  complete- 
ly obliterate  the  calibre  of  the  vein  by  compression.  To  ef- 
fect this,  very  considerable  force  must  be  used,  and  all  the 
small  anastomosing  veins  on  the  posterior  part  of  the  thigh  be 
compressed :  the  direful  consequences  of  which  have  already 
been  explained.  All  this  we  think  may  be  avoided  by  tying 
up  the  inguinal  artery;  for  then  the  blood  will  be  prevented 
from  flowing  through  it,  and  all  its  numerous  branches  will  im- 
mediately cease  to  pulsate ;  consequently,  the  veins  are  not 
only  debarred  their  source  of  blood,  but  even  the  quantity  which 
they  already  contain  is  prevented  from  circulating  by  the  re- 
moval of  the  visa  tergo  given  to  them  by  the  pulsative  motion 
of  the  arteries.  Therefore,  very  slight  compression  will  be 
required  to  restrain  the  blood. 

It  may  be  asked,  why  not  direct  an  elevated  position  of 
the  foot  in  this  case,  as  well  as  any  other  ?   We  reply  :  the  re- 


[    -?    J 

iraclion  of  the  ends  of  the  divided  vein  will  be  so  considera- 
ble, and  the  external  opening  so  free,  that  it  will  be  necessa- 
r3'  to  completely  obliterate  the  calibre  of  the  vein  before  the 
hemorrhage  can  be  restrained.  Consequently,  when  the  vein 
fills  with  blood  (as  it  will  do  if  the  artery  be  not  tied  or  other- 
wise compressed)  there  will  be  a  column  of  blood  as  high  as 
the  elevation  of  the  foot  to  be  supported  by  the  compresses  and 
bandages.  This,  therefore,  would  not  only  be  very  difficult 
to  accomplish,  but,  even  though  it  should  be  effected,  the  com- 
pression which  would  thereby  unavoidably  be  made  upon  the 
niimerous,  though  small  anastomosing  branches  of  veins  on 
the  posterior  part  of  the  thigh  would,  as  we  have  already  ob- 
served, completely  obstruct  all  circulation  through  them.  But 
where  is  the  objection  to  tying  up  the1  inguinal  artery  ?  Surely, 
the  numerous  and  generally  successful  cases  of  tied  arteries, 
is  sufficient  to  do  away  all  objection  ;  and  when  we  recount 
the  advantages  thus  obtained,  they  will  be  found  by  no  means 
inconsiderable.  Our  patient  can  then  have  his  wound  dressed 
easily.  If  necessary,  a  stitch  or  two  may  be  used  to  bring 
the  retracted  integuments  in  close  coaptation.  Lint,  com- 
presses, and  short  adhesive  straps  will  be  sufficient  to  restrain 
the  bleeding:  then,  by  laying  him  in  bed  on  his  well  side,  his 
lame  leg  may  be  placed  in  an  easy,  natural  position,  and  sup- 
ported by  pillows,  cushions,  &c.  thus  allowing  the  numerous, 
though  small  anastomosing  arteries  and  veins  of  the  internal 
iliac  and  profunda,  the  most  perfect  liberty  to  enlarge  and  sup- 
port the  limb  by  a  free  circulation  of  blood. 

Of  Lacerated  or  Contused  Wounds  of  the  In- 
guinal Vein. 

Wounds  of  this  description  are  more  difficult  to  heal, 
more  insidiou?,  and  consequently  more  dangerous  than  incis- 
ed ones  of  the  same  extent.  The  contusion  so  diminishes  and 
sometimes  even  destroys  the  vitality  of  the  part,  that  exten- 
sive s'oughing  is  very  liable  to  take  place,  and  consequently, 


[  M  ] 

secondary  hemorrhage  is  to  be  looked  for,  and  particularly  to 
be  dreaded. 

Treatment. — A  detail  of  treatment  is  deemed  quite  un- 
necessary. The  principles  promulgated  in  the  preceding  in- 
stances, are  applicable  in  the  present. 

Of  Ulcerated  Wounds  of  the  Inguinal  Vein  ;  or, 
Wounds  caused  by  a  Sloughing  Ulcer  at  the 
Groin. 

These  varieties  have  been  named  merely  because  we 
think  the  same  principles  of  treatment  applicable  to  them. 
The  only  difference  would  be  in  the  local  remedies,  and  the 
nature  of  the  affection  must  dictate  them ;  but  as  wounds  of 
this  description,  and  also  those  which  are  lacerated  or  con- 
tused, take  a  long  time  to  heal,  and  are  particularly  danger- 
ous on  account  of  their  liability  to  hemorrhage,  it  becomes 
more  imperiously  necessary  to  take  up  the  inguinal  artery. 

Of  Wounds  of  the  Proper  Femoral  Vein. 

We  have  nothing  in  particular  to  offer  on  this  subject : 
however,  it  may,  perhaps,  be  proper  to  observe,  that  in 
wounds  of  this  vein,  whether  inei3ed,  lacerated  or  ulcerated, 
we  think  it  never  will  be  necessary  to  take  up  the  inguinal  ar- 
tery, but  that  an  elevated  position  of  the  foot,  with  compres- 
sion applied  directfy  over  the  wounded  vein,  is  all  that  frill 
be  necessary. 

It  should  be  recollected  that  the  saphena  vein  is  sufficient 
io  carry  en  the  circulation  even  though  the  proper  femoral 
vein  be  obliterated ;  therefore,  in  making  compression  on  the 
proper  femoral,  pressure  on  the  saphena  should  be  avoided  as 
much  as  possible.  Our  views  of  the  proper  method  of  apply- 
ing compression  are  the  following  :— have  three  long  and  wide 
splints;  arrange  them  longitudinally  around  the  thigh  so  as  to 
leave  a  space  on  the  inner  and  anterior  part  of  the  thigh,  or 
along  the  course  of  the  saphena  vein,  about  two  inches  wide. 
Apply  a  roller  over  the  splints  just  firm  enough  to  keep  them 
steady.     Then  one  inch  distant  from  the  wound,  on  the  low 


[    29    ] 

er  portion  of  the  vein,  or  that  portion  next  the  foot,  place  the 
tourniquet.  Have,  then,  some  graduated  compresses,  formed 
in  a  conical  shape ;  place  the  apex  of  the  cone  over  the 
wounded  vein — the  other  end  of  the  compress,  or  its  base, 
under  the  strap  of  the  tourniquet,  then  turn  the  screw  of  the 
tourniquet,  and  compression  will  be  made  more  directlj  upon 
the  wounded  vein. 

It  is  thought  best  to  apply  the  compression  a  little  below 
the  oriSce  of  the  wound,  for  then  the  wound  may  be  dressed 
without  disturbing  the  splints,  compresses,  &c.  and  not  only 
that,  but  it  is  presumed  the  wound  would  heal  quicker.  But 
compression  applied  in  this  manner  never  will  be  necessary 
except  when  the  vein  is  divided,  or  nearly  so. 

When  the  wound  of  the  vein  is  small,  an  elevated  posi- 
tion of  the  foot  will  so  much  lessen  the  volume  of  blood  in 
the  vein  and  facilitate  the  circulation  of  that  which  remains, 
that  the  veins,  in  a  great  measure,  will  be  kept  empty;  con- 
sequently, there  will  not  be  lateral  pressure  enough  to  force 
the  blood  out  of  the  wound.  Lint,  lateral  compresses,  and 
adhesive  straps  to  secure  them,  we  presume,  is  all  that  will  be 
necessary. 

Of  the  period  of  time  an  elevated  position  of  the  foot  should 
be  persisted  in  : — Our  knowledge  of  the  healing  process  will  be 
our  guide  in  this  respect.  If,  therefore,  the  wound  be  a  longitu- 
dinal one,  and  small  in  extent,  an  elevated  position  may  not  be 
observed  longer  than  forty-eight  hours;  for  by  that  time  we 
may  fairly  conclude  the  lips  of  the  wound  have  united,  When, 
however,  the  wound  is  more  extensive,  the  process  of  healing 
will  be  slower;  consequently,  an  elevated  position  of  the  foot 
must  be  continued  longer  :  also,  as  venous  hemorrhage  is  very 
liable  to  recur;  all  exertion  should  be  proscribed  until  the 
wound  be  fairly  healed. 

It  may  be  proper  in  this  place  to  observe,  that  the  lint 
which  was  applied  immediately  to  the  orifice  of  the  wound, 
should  not  be  removed  until  it  is  loosened  by  the  process  of  ul- 


[    30   ] 

ceralion  ;  for  it  is  not  improbable  that  within  the  space  of 
twenty-four  hours  (he  circulation  may  be  so  far  restored  ia 
the  limb  as  to  produce,  if  ihe  lint  and  close  dressings  be  for- 
cibly detached,  a  dangerous  hemorrhage;  and  not  only  that,  a 
premature  removal  of  the  dressings  and  lint  may  disturb  the 
healing  process,  and  thereby  cause  the  inflammation  to  rage 
violently,  which,  eventually,  may  be  either  very  difficult  to 
suppress,  or  fatal  to  the  patient. 

If  the  elevated  position  of  the  foot  should,  after  a  time, 
produce  numbness  and  coldness  of  the  leg  and  foot,  reason 
\vould  dictate  to  us  the  propriety,  and  even  necessity  of  low- 
ering the  limb. 


THE    END. 


errata; 

Page  4— 10th  line,  for  "  adhesiev"  read  "  adhesive." 
"      6— 50th  line,  for  "  oplhaliaai"  read  "  oplhalmia." 
m     g — The  note  being  misplaced,  the  reader  is  requested  to  omit  it 

altogether. 
"   23— 3d  line,  for  "pressure"  read  "presence." 


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$ttltQL 


VALENTINE  MOTT,  M.  D. 

Professor  of  Surgery. 


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